Please provide a working phone number for our driver to contact your prior to delivery.
Demographic Information:
Emergency Contact Information:
Physical Qualifications for Program: Are you able to cook your own meals?
Do you have COVID-19? (proof must be provided)
Do you have a health condition?
Are you quarantined because of COVID-19? (proof must be provided)
Food Delivery Preferences: Deliveries will be scheduled once a week according to your zip code, we will get as close to your preferred time as possible.
Select two days and a time you would prefer your groceries delivered:
What is your preferred delivery time?
Do you have any food allergies?
List your food allergies?
What foods do you enjoy on a weekly basis? Do you have any cultural food preferences? Do you prefer Hispanic food, African American food, Cambodian food, Filipino food, or other?
Please list your cultural food preferences:
Geographic Information Do you live in an apartment, house and or gated community?
Drivers are instructed to leave your groceries at your front door, ring the doorbell or knock and go to sidewalk and wait to make sure you receive your groceries. Drivers will wait at the side walk to ensure you open the door and receive your groceries. If your groceries bags are too heavy to carry, please remove a few items at a time and take the items into your home.
Comments/Additional Information You Would Like Us To Know:
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